Basic Information
| Provider Information | |||||||||
| NPI: | 1881198992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLE DEL SOL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3877 N 7TH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850145061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022586797 | ||||||||
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| Practice Location | |||||||||
| Address1: | 334 W 10TH PL STE 100 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852013499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022586797 | ||||||||
| FaxNumber: | 6022488113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2018 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | HEREDIA | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICCER | ||||||||
| AuthorizedOfficialTelephone: | 6022586797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 871351 | 05 | AZ | MEDICAID |